Dutch doctors withhold/withdraw treatment in many elderly patients

Dutch doctors withhold/withdraw treatment in a substantial proportion of elderly patients, reveals research published online in the Journal of Medical Ethics.

But their decisions don't seem to be driven by ageism; rather, they are more likely based on considerations of comfort and respect and the avoidance of futile treatment, conclude the researchers.

In a bid to assess whether certain age groups are more likely to have treatment withheld or withdrawn, the researchers looked at a sample of deaths, stratified according to whether end of life decisions were likely or not, and occurring between August and November 2010 in The Netherlands.

All doctors who certified a death were sent a questionnaire about end of life decision-making.

In all, questionnaires were completed for 6600 patients, one in three of whom was aged between 65 and 79, and four out of 10 of whom were aged 80 and above.

The oldest patients were significantly more likely to be women and unmarried. And they were more likely to have dementia and to be in a nursing home than patients below the age of 80.

Across the entire sample, treatment was withheld/withdrawn in 37% of cases, but was more common among the 80+ age group: 42% compared with 36% for 65-79 year olds and 25% for 17-64 year olds.

Artificial feeding and fluids was the treatment most likely to be withheld across the entire sample, followed by antibiotics. Treatment was twice as likely to be withheld in those aged 80+ as it was in the youngest age group.

Similarly, drug treatment was most likely to be withdrawn across the entire sample (56%), but its withdrawal was 2.5 times as common among those aged 80+.

The most common reasons doctors gave for forgoing treatment included no chance of improvement (72%) and the futility of prolonging treatment (62%). They were also around twice as likely to mention loss of dignity and respect for the patient's wishes for those aged 80+.

In more than half of cases (56%) there was no discussion about end of life decisions with the patient, but in most of these (93%) the patient didn't have sufficient capacity.

Around one in three doctors (35%) judged that their decision had not shortened life; around one in four (27%) said that it had shortened life by up to a week.

"Based on our results, we cannot assume that age related differences in withholding/withdrawing treatment are the result of ageism," write the authors.

"In fact, our findings indicate that care for older people is focused on providing comfort and avoiding burdensome treatment, suggesting better acceptance that these patients are nearing death," they conclude.

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